BACKGROUND

Contraception is crucial for helping women to avoid unintended pregnancies, and it has myriad health, social and economic benefits for women and families. Since the mid-1990s, 28 states have required health insurance plans regulated by the state that provide coverage of prescription drugs and devices to also cover prescription contraceptives.

Federal law, under a provision of the Affordable Care Act of 2010, expanded on these state policies in several ways. The federal contraceptive coverage guarantee applies to most private health plans nationwide; it specifically requires coverage for 18 methods of contraception used by women (including female sterilization), along with related counseling and services; and it requires this coverage to be provided without any cost sharing by patients (i.e., out-of-pocket payments, such as copayments or deductibles). In administering this coverage, health plans may use formularies, prior authorization requirements and similar restrictions to affect patients’ choices only within a method category, but not across method types. In other words, for example, health plans may favor one type of hormonal IUD over another, but they may not direct patients to use IUDs over oral contraceptives. 

More recently, some states have amended and expanded their own requirements to match the standard set in the federal guarantee by specifically requiring coverage for the full range of contraceptive methods, counseling and services used by women; eliminating out-of-pocket costs; and limiting other health plan restrictions. Moreover, some of these new state provisions go beyond the federal guarantee, by requiring coverage for contraceptive methods that are available over the counter without requiring the patient to first obtain a prescription, ensuring that women may receive a six-month or one-year supply of a method at one time (rather than more typical one- or three-month supplies), or requiring coverage of male sterilization without patient out-of-pocket costs.

STATE LAWS AND POLICIES

For a chart of current laws and policies in each state related to contraceptive coverage, see Insurance Coverage of Contraceptives.

For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.

RELEVANT DATA AND ANALYSIS

Importance of Method Choice

Contraception is widely used to help women avoid unintended pregnancies, and having a choice among a wide range of contraceptive methods helps them to do so.

  • More than 99% of women aged 15–44 who have ever had sexual intercourse have used at least one contraceptive method.1
  • Although using any method of contraception is more effective in preventing pregnancy than not using a method at all, every woman should have access to the full range of contraceptives to find the methods that best fit her needs.2
  • Contraceptive methods are not interchangeable. Methods differ in terms of effectiveness, side effects, drug interactions, use of hormones, cost, confidentiality concerns and the degree of control women have over their use. A woman’s contraceptive needs may vary over her reproductive lifetime: More than three-fourths of U.S. women have used three or more different methods by age 44.1
  • The desirability of a particular contraceptive method may vary depending on a woman’s preferences and situation. For example, some women may need a method that can be used just before having sex, while others (or the same women at different times) may prefer a method that does not require the user to remember it each time.
  • In a 2010 study of women seeking abortion, currently available contraceptive methods had between 37% and 67% of what participants considered extremely important features. Fewer than one-third of women rated most methods as “good” matches (meeting 75% of their needs).3
  • Satisfaction with a method influences whether women use their method consistently and correctly. For example, according to surveys in 2004–2005, 48% of dissatisfied pill users had skipped at least one pill in the previous three months, compared with 35% of completely satisfied pill users. Overall, 30% of neutral or dissatisfied method users reported a temporal gap in use, compared with 12% of completely satisfied users.4
  • Consistent use matters: Two-thirds of women at risk for unintended pregnancy who consistently and correctly used a contraceptive method accounted for only 5% of unintended pregnancies in 2008.5

Documented Benefits of Contraception

Contraception has health, social and economic benefits for women and their families.

  • Contraceptive use helps women control the timing, number and spacing of births, thus reducing the likelihood of premature birth or low birth weight.6
  • Contraceptive use can prevent preexisting health conditions from worsening and new health problems from arising as a result of unintended pregnancy. Unintended pregnancy can exacerbate existing health conditions such as diabetes, hypertension and heart disease,7 and is also a risk factor for depression in adults.8,9
  • Isolating contraceptive services from broader health insurance coverage can force women to receive their contraceptive care separately from other primary and preventive services. This can disrupt continuity of care, reduce patients’ ability to see the provider of their choice at the time or place they need, and stigmatize contraceptive services by treating them as different from or less important than other health care.10
  • Contraception can help women meet their educational, financial and other personal goals.
    • In a 2016 national survey of women aged 18–44, a majority of respondents agreed that an unplanned birth would have negative effects on a woman’s life, including her education, job, income and mental health.11 Most respondents also said that contraception has positive effects beyond preventing pregnancy, such as reduced stress, health benefits and continued ability to work.12
    • In a 2011 study examining women’s reasons for using contraceptives, many women reported that using birth control to prevent pregnancy enabled them to support themselves financially (56%), meet their educational goals (51%) and get or keep a job (50%).13
    • Economic analyses have found positive associations between the availability of oral contraceptives and U.S. women’s education, labor force participation and average earnings, as well as a reduction in the wage gap between women and men.14

Cost Barriers to Access

The cost of methods can reduce women’s contraceptive choices. Insurance coverage—particularly without cost sharing—can help women overcome this barrier to using a preferred method.

  • Cost matters to women when choosing a contraceptive method.
    • Among women aged 18–44 surveyed in 2016, more than 70% said that it was “extremely or quite important” for their contraceptive method to be low cost.12
    • Some of the most effective contraceptive methods are also the most expensive. For example, an IUD is 88 times as effective as a male condom in preventing pregnancy during the first year of typical use,10,15 but the cost of an IUD can be much higher—sometimes exceeding $500 (not including costs related to insertion).16 The total cost of initiating a long-acting method generally exceeds $1,000.17 To put that cost in perspective, beginning to use one of these devices costs nearly a month’s salary for a woman working full time at the federal minimum wage of $7.25 an hour.
    • In a 2007–2008 study, women who had to pay high out-of-pocket costs were significantly less likely to obtain an IUD than women who paid less than $50. Overall, only 25% of women in the study who requested an IUD had one placed after learning the associated costs.18
    • In a study conducted prior to implementation of the federal contraceptive coverage guarantee, almost one-third of women reported that they would change their contraceptive method if cost were not an issue.19
  • Numerous studies have demonstrated that even seemingly small copayments and other cost-sharing requirements can dramatically reduce preventive health care use, particularly among low-income Americans.20
  • Extensive empirical evidence demonstrates that eliminating costs leads to more effective and continuous use of contraception.2
    • According to data from a 2006–2008 survey, women aged 15–44 with private health insurance living in states that required private insurers to cover prescription contraceptives were 64% more likely to use a contraceptive method during each sexually active month than those living in states with no such requirement, even after accounting for differences in education and income.21
    • In a 2015 survey of uninsured women, nearly half of respondents said that having health insurance would help them afford birth control, choose a better method and use that method consistently.22

Benefits of the Federal Coverage Guarantee

The federal contraceptive coverage guarantee has had important benefits for women.

  • The contraceptive coverage guarantee requires most private insurance plans to cover the full range of contraceptive methods for women without cost sharing (copayments or deductibles).23
  • Fewer women pay out of pocket for their birth control since implementation of the contraceptive coverage guarantee.
    • Between fall 2012 and spring 2014 (during which time the coverage guarantee went into wide effect), the proportion of privately insured women who paid nothing out of pocket for oral contraceptives increased from 15% to 67%. Similar increases occurred among those using injectable contraceptives, the vaginal ring and IUDs.24
    • In a 2016 national survey, two-thirds of women reported that the full cost of their prescription birth control method had been covered by their health insurance plan or another program in the previous six months.12
    • Contraceptive pill users saved an estimated average of $255 in copayments in 2013 because of the contraceptive coverage guarantee.25
    • As of 2017, nearly 58 million women had coverage of birth control without cost sharing.25
  • Eliminating cost sharing in insurance coverage can reduce financial barriers to the use of a chosen contraceptive method.
    • In a study of 2010–2013 health insurance claims, women using generic birth control pills who had contraceptive coverage without cost sharing following the coverage mandate’s implementation were more likely to continue and consistently use their method than women using generic pills with even modest out-of-pocket costs.26
    • In a 2015 survey of women who had health insurance and used a hormonal contraceptive method, two-thirds of respondents had no copayments. Among women with no copayments, 80% reported that paying nothing out of pocket helped them to afford and use their birth control, more than 70% reported it helped them use their birth control consistently and 60% reported it helped them choose a better method.22
  • Several studies have found that contraceptive coverage without cost sharing has influenced women’s contraceptive method choices. However, the influence of the guarantee on overall contraceptive use is still unclear.
    • A study of private health insurance claims from 2008–2014 found that the reduction in cost sharing because of the contraceptive coverage guarantee was tied to a significant increase in the use of prescription methods, particularly long-acting methods.27
    • Another study of health insurance claims from 2010–2013 showed that the rate of discontinuation and inconsistent use of contraception declined among women using generic oral contraceptive pills after the contraceptive mandate’s implementation; among women using brand-name oral contraceptives, discontinuation and nonadherence rates declined when the out-of-pocket expense was higher than $30.26 
    • A study of contraceptive use found that between 2012 and 2015, use of prescription birth control pills increased among sexually inactive women, suggesting that more women were able to use the pill for reasons other than contraception after implementation of the contraceptive coverage guarantee.22
    • The same study found that since the guarantee’s implementation, there has been no change in overall contraceptive use among women at risk of unintended pregnancy, suggesting that insurance coverage may not have been the only barrier preventing women from obtaining the method of their choice.22
  • A 2017 study projected that for every one million women aged 15–44 who lose private insurance coverage for contraceptives, there would be 33,000 more unintended pregnancies and 13,000 more abortions each year.28

State Actions to Reinforce the Coverage Mandate

Implementing or expanding state requirements could reinforce the federal contraceptive coverage guarantee and help state agencies enforce it.

  • In 2015, studies by the National Women’s Law Center and the Kaiser Family Foundation identified several major problems areas with insurance plans’ interpretation and implementation of the guarantee. For example, many plans were not providing coverage for all contraceptive methods used by women, were only covering generic equivalents of brand-name birth control products or were charging out-of-pocket fees for services associated with receiving birth control.29,30
  • In 2013 and 2015, the federal government issued details clarifying the contraceptive coverage guarantee, including that insurers must cover 18 specific methods without cost sharing, coverage must include all services related to contraception (such as counseling, insertion and removal of IUDs and implants, and follow-up care), and issuers may utilize medical management techniques (such as requiring prior authorization from the health plan) only for products within a given method category, but not in a way that interferes with a woman’s choice across methods.31,32
  • Following the 2015 federal guidance, the National Women’s Law Center documented that fewer consumers reported their insurance plans were excluding coverage of specific birth control methods or limiting coverage to generic versions.33 However, some plans continued to exclude coverage for tests or other services associated with receiving birth control and to impose a maximum age limit on coverage.

Coverage Guarantee Expansion Options

Expanding the federal contraceptive coverage guarantee to include insurance coverage for over-the-counter methods without a prescription, extended supplies of contraceptives at one time and methods of contraception used by men can help people get and consistently use the method of their choice.

  • Under the contraceptive coverage guarantee, insurers only have to cover over-the-counter contraceptives for which women have a prescription. Coverage of over-the-counter contraceptive methods without need for a prescription has the potential to improve contraceptive use and, in turn, reduce unintended pregnancy rates, especially among women who lack the time to visit a health care provider, would need to arrange for child care or otherwise find it difficult to seek out a prescription.34
  • Currently, most insurance plans cover only 1–3 months’ worth of oral contraceptives at a time. When women run out of pills or have difficulty obtaining prescription refills, they may experience gaps in use or stop using contraceptives altogether, which in turn may lead to unintended pregnancies.
    • A 2007–2009 study found that women who received a seven-month supply of oral contraceptive pills at one time without cost sharing were more likely to continue use for six months than those who received a three-month supply.35
    • A 2006 study found that women who received a full year’s supply of oral contraceptives without cost sharing were less likely to become pregnant within a year than women who received a one- or three-month supply.36
  • As it currently stands, the federal contraceptive coverage guarantee does not include methods used by men (vasectomy or male condoms), although these methods have proven health benefits for women and couples. Vasectomies are less invasive, have lower health risks and are less expensive than female sterilization. Male condoms are an important primary and backup method of contraception and have the added benefit that they prevent STIs.37,38

DATA CENTER

RECENT STATE ACTION ON THIS ISSUE

States that have addressed this issue over the past three years are listed below.

E: State enacted a relevant measure

V: State vetoed measure

A: State adopted measure in at least one chamber

 

States that have expanded on the contraceptive coverage guarantee in the Affordable Care Act

Alaska (2018)

A

Connecticut (2018)

E

Delaware (2018)

E

District of Columbia (2018)

E

Hawaii (2017)

A

Illinois (2016)

E

Maine (2017)

E

Maryland (2016)

E

Massachusetts (2017)

E

Nevada (2017)

E

New Hampshire (2018)

E

New Mexico (2017)

A

New York (2018)

A

Oregon (2017)

E

Vermont (2016)

E

Washington (2018)

E

 

States that allow health insurance enrollees to obtain an extended supply of contraceptives

Alaska

A

California (2016)

E

Colorado (2017)

E

Connecticut (2018)

E

Delaware (2018)

E

District of Columbia (2018)

E

Hawaii (2016)

E

Illinois (2016)

E

Iowa (2016)

A

Maine (2017)

E

Maryland (2016)

E

Massachusetts (2017)

E

Missouri (2016)

A

Nevada (2017)

E

New Hampshire (2018)

E

New Jersey (2017)

E

New Mexico (2017)

A

New York (2018)

A

Oregon (2017)

E

Rhode Island (2018)

E

South Carolina (2017)

A

Vermont (2016)

E

Virginia (2017)

E

Washington (2017)

E

 

States that include coverage for over-the-counter contraceptive methods without a prescription

Connecticut (2018)

E

Delaware (2018)

E

District of Columbia (2018)

E

Hawaii (2016)

A

Iowa (2016)

A

Massachusetts (2017)

E

Missouri (2016)

A

New Mexico (2017)

A

New York (2018)

A

Oregon (2017)

E

Washington (2018)

E

 

States that include male sterilization in health insurance coverage

Alaska (2018)

A

Colorado (2016)

A

Hawaii (2018)

A

Illinois (2016)

E

Maryland (2016)

E

New Mexico (2017)

A

New York (2018)

A

Oregon (2017)

E

Vermont (2016)

E

Washington (2018)

E

 

 

REFERENCES

1. Daniels K, Mosher WD and Jones J, Contraceptive methods women have ever used: United States, 1982–2010, National Health Statistics Reports, 2013, No. 62, http://www.cdc.gov/nchs/data/nhsr/nhsr062.pdf.

2. Declaration of Dr. Lawrence Finer in Support of Plaintiffs’ Motion for Preliminary Injunction, State of California v. Wright, N.D. Cal., 2017.

3. Lessard L et al., Contraceptive features preferred by women at high risk of unintended pregnancy, Perspectives on Sexual and Reproductive Health, 2012, 44(3):194–200, http://onlinelibrary.wiley.com/doi/10.1363/4419412/full.

4. Frost JJ, Darroch JE and Remez L, Improving contraceptive use in the United States, In Brief, New York: Guttmacher Institute, 2008, https://www.guttmacher.org/report/improving-contraceptive-use-united-states.  

5. Sonfield A, Hasstedt K and Gold RB, Moving Forward: Family Planning in the Era of Health Reform, New York: Guttmacher Institute, 2014, https://www.guttmacher.org/report/moving-forward-family-planning-era-health-reform

6. Kavanaugh ML and Anderson RM, Contraception and Beyond: The Health Benefits of Services Provided at Family Planning Centers, New York: Guttmacher Institute, 2013, https://www.guttmacher.org/report/contraception-and-beyond-health-benefits-services-provided-family-planning-centers

7. Lawrence HC, Testimony of American Congress of Obstetricians and Gynecologists (ACOG), submitted to the Committee on Preventive Services for Women, Institute of Medicine, Jan. 12, 2011, http://www.nationalacademies.org/hmd/~/media/8BA65BAF76894E9EB8C768C01C84380E.ashx.

8. Herd P et al., The implications of unintended pregnancies for mental health in later life, American Journal of Public Health, 2016, 106(3):421–429, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4815713/.

9. U.S. Preventive Services Task Force, Screening for depression in adults: recommendation statement, American Family Physician, 2016, 94(4):340A–340D, http://www.aafp.org/afp/2016/0815/od1.html.

10. Brief of the Guttmacher Institute and Professor Sara Rosenbaum as Amici Curiae in Support of the Government, Zubik v. Burwell, No. 14-1418, 2016, http://www.guttmacher.org/sites/default/files/article_files/guttmacher_zubik_scotus_amicus_brief.pdf.

11. Johnston EM et al., Prevalence and Perceptions of Unplanned Births, Washington, DC: Urban Institute, 2017, https://www.urban.org/sites/default/files/publication/88801/prevalence_and_perceptions_of_unplanned_births.pdf.

12. Johnston EM et al., Access to Contraception in 2016 and What It Means to Women, Washington, DC: Urban Institute, 2017, https://www.urban.org/sites/default/files/publication/87691/2001113-access-to-contraception-in-2016-and-what-it-means-to-women.pdf.

13. Frost JJ and Lindberg LD, Reasons for using contraception: perspectives of U.S. women seeking care at specialized family planning clinics, Contraception, 2013, 87(4):465–472, http://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.contraception.2012.08.012.pdf.

14. Sonfield A et al., The Social and Economic Benefits of Women’s Ability to Determine Whether and When to Have Children, New York: Guttmacher Institute, 2013, https://www.guttmacher.org/sites/default/files/report_pdf/social-economic-benefits.pdf.

15. Sundaram A et al., Contraceptive failure in the United States: estimates from the 2006–2010 National Survey of Family Growth, Perspectives on Sexual and Reproductive Health, 2017, 49(1):7–16, https://www.guttmacher.org/journals/psrh/2017/02/contraceptive-failure-united-states-estimates-2006-2010-national-survey-family.

16. Armstrong E et al., Intrauterine Devices and Implants: A Guide to Reimbursement, second ed., Regents of the University of California, ACOG, National Family Planning & Reproductive Health Association, National Health Law Program and National Women’s Law Center (NWLC), 2015, https://www.nationalfamilyplanning.org/file/documents----reports/LARC_Report_2014_R5_forWeb.pdf.

17. Eisenberg D, McNicholas C and Peipert JF, Cost as a barrier to long-acting reversible contraceptive (LARC) use in adolescents, Journal of Adolescent Health, 2013, 52(4):S59–S63, http://www.jahonline.org/article/S1054-139X(13)00054-2/fulltext.

18. Gariepy AM et al., The impact of out-of-pocket expense on IUD utilization among women with private insurance, Contraception, 2011, 84(6):e39–e42, http://www.contraceptionjournal.org/article/S0010-7824(11)00432-X/fulltext.

19. Frost JJ and Darroch JE, Factors associated with contraceptive choice and inconsistent method use, United States, 2004, Perspectives on Sexual and Reproductive Health, 2008, 40(2):94–104, https://www.guttmacher.org/about/journals/psrh/2008/factors-associated-contraceptive-choice-and-inconsistent-method-use-united.  

20. S, Ubri P and Zur J, The Effects of Premiums and Cost Sharing on Low-Income Populations: Updated Review of Research Findings, Menlo Park, CA: Kaiser Family Foundation (KFF), 2017, https://www.kff.org/medicaid/issue-brief/the-effects-of-premiums-and-cost-sharing-on-low-income-populations-updated-review-of-research-findings/.

21. Magnusson BM et al., Contraceptive insurance mandates and consistent contraceptive use among privately insured women, Medical Care, 2012, 50(7):562–568.

22. Bearak JM and Jones RK, Did contraceptive use patterns change after the Affordable Care Act?: A descriptive analysis, Women’s Health Issues, 2017, 27(3):316–321, http://www.whijournal.com/article/S1049-3867(17)30029-4/fulltext.

23. Health Resources and Services Administration, U.S. Department of Health and Human Services, Women’s preventive services guidelines, 2016, https://www.hrsa.gov/womens-guidelines-2016/index.html.

24. Sonfield A et al., Impact of the federal contraceptive coverage guarantee on out-of-pocket payments for contraceptives: 2014 update, Contraception, 2015, 91(1):44–48.

25. NWLC, New data estimates 57.6 million women have coverage of birth control without out-of-pocket costs, 2017, https://nwlc.org/wp-content/uploads/2017/09/New-Preventive-Services-Estimates-2.pdf.

26. Pace LE, Dusetzina SB and Keating NL, Early impact of the Affordable Care Act on oral contraceptive cost sharing, discontinuation, and nonadherence, Health Affairs, 2016, 35(9):1616–1624, http://content.healthaffairs.org/content/35/9/1616.short.

27. Carlin CS, Fertig AR and Down BE, Affordable Care Act’s mandate eliminating contraceptive cost sharing influenced choices of women with employer coverage, Health Affairs, 2016, 35(9):1608–1615.

28. Canestaro W et al., Implications of employer coverage of contraception: cost‐effectiveness analysis of contraception coverage under an employer mandate, Contraception, 2017, 95(1):77–89.

29. NWLC, State of Birth Control Coverage: Health Plan Violations of the Affordable Care Act, 2015, https://nwlc.org/resources/state-birth-control-coverage-health-plan-violations-affordable-care-act/.

30. Sobel L, Salganicoff A and Kurani N, Coverage of Contraceptive Services: A Review of Health Insurance Plans in Five States, KFF, 2015, http://kff.org/private-insurance/report/coverage-of-contraceptive-services-a-review-of-health-insurance-plans-in-five-states/.

31. U.S. Department of Labor, Frequently Asked Questions About Affordable Care Act Implementation (Part XII), 2013, http://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-xii.pdf.

32. U.S. Department of Labor, Frequently Asked Questions About Affordable Care Act Implementation (Part XXVI), 2015, http://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-xxvi.pdf.

33. NWLC, The Affordable Care Act’s Birth Control Benefit: Progress on Implementation and Continuing Challenges, 2016, https://nwlc.org/resources/the-affordable-care-acts-birth-control-benefit-progress-on-implementation-and-continuing-challenges/

34. Barot S, Moving oral contraceptives to over-the-counter status: policy versus politics, Guttmacher Policy Review, 2015, 18(4):85–91, https://www.guttmacher.org/about/gpr/2015/11/moving-oral-contraceptives-over-counter-status-policy-versus-politics.

35. White KO and Westhoff C, The effect of pack supply on oral contraceptive pill continuation: a randomized controlled trial, Obstetrics & Gynecology, 2011, 118(3):615–622.

36. Foster DG et al., Number of oral contraceptive pill packages dispensed and subsequent unintended pregnancies, Obstetrics & Gynecology, 2011, 117(3):566–572.

37. Sonfield A, The women’s health amendment is getting an update. What should it include? Health Affairs Blog, 2016, http://healthaffairs.org/blog/2016/09/14/the-womens-health-amendment-is-getting-an-update-what-should-it-include/.

38. Sonfield A, Rounding out the contraceptive coverage guarantee: why ‘male’ contraceptive methods matter for everyone, Guttmacher Policy Review, 2015, 18(2):34–39, https://www.guttmacher.org/about/gpr/2015/06/rounding-out-contraceptive-coverage-guarantee-why-male-contraceptive-methods.